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[ Home ](https://mdster.com) 2. [ Blog ](https://mdster.com/blog) 3. [ Case Discussion ](https://mdster.com/blog?category=case-discussion) 4. Abusive Head Trauma in Infants: A Case-Based Diagnostic Approach [ Case Discussion ](https://mdster.com/blog?category=case-discussion) Abusive Head Trauma in Infants: A Case-Based Diagnostic Approach ================================================================== A four-month-old with subdural hemorrhage tests the boundary between urgent neurocritical care and careful safeguarding. [ MDster Editorial Team ](https://mdster.com/about) · Oct 10, 2026 · 6 min read · 48 [ Reviewed by Dr. Ali Ragab, MBBCH, MSc, MCAI ](https://mdster.com/medical-reviewers/dr-ali-ragab) [Editorial Policy](https://mdster.com/editorial-policy) | [Corrections Policy](https://mdster.com/corrections) [ Pediatrics ](https://mdster.com/blog?tag=pediatrics) [ Child Protection ](https://mdster.com/blog?tag=child-protection) [ Abusive Head Trauma ](https://mdster.com/blog?tag=abusive-head-trauma) [ Pediatric Neurotrauma ](https://mdster.com/blog?tag=pediatric-neurotrauma) ![Abusive Head Trauma in Infants: A Case-Based Diagnostic Approach](https://mdster.com/storage/blog/images/abusive-head-trauma-in-infants-a-case-based-diagnostic-approach.png) Share this article Share this post On this page 1. [ First, protect the brain ](#first-protect-the-brain) 2. [ Stabilization before investigation ](#stabilization-before-investigation) 3. [ Read the imaging without overdating it ](#read-the-imaging-without-overdating-it) 4. [ CT answers the emergency question; MRI adds context ](#ct-answers-the-emergency-question-mri-adds-context) 5. [ Test competing explanations, not just the leading one ](#test-competing-explanations-not-just-the-leading-one) 6. [ Four medical differentials worth defending at the board ](#four-medical-differentials-worth-defending-at-the-board) 7. [ Look for injuries the infant cannot report ](#look-for-injuries-the-infant-cannot-report) 8. [ A coordinated occult-injury workup ](#a-coordinated-occult-injury-workup) 9. [ Safeguarding and prognosis ](#safeguarding-and-prognosis) 10. [ Key Points for Board Exams ](#key-points-for-board-exams) 11. [ Frequently Asked Questions ](#blog-faqs) 12. [ References ](#references-heading) On this page 1. [ First, protect the brain ](#first-protect-the-brain) 2. [ Stabilization before investigation ](#stabilization-before-investigation) 3. [ Read the imaging without overdating it ](#read-the-imaging-without-overdating-it) 4. [ CT answers the emergency question; MRI adds context ](#ct-answers-the-emergency-question-mri-adds-context) 5. [ Test competing explanations, not just the leading one ](#test-competing-explanations-not-just-the-leading-one) 6. [ Four medical differentials worth defending at the board ](#four-medical-differentials-worth-defending-at-the-board) 7. [ Look for injuries the infant cannot report ](#look-for-injuries-the-infant-cannot-report) 8. [ A coordinated occult-injury workup ](#a-coordinated-occult-injury-workup) 9. [ Safeguarding and prognosis ](#safeguarding-and-prognosis) 10. [ Key Points for Board Exams ](#key-points-for-board-exams) 11. [ Frequently Asked Questions ](#blog-faqs) 12. [ References ](#references-heading) A four-month-old arrives lethargic after 24 hours of vomiting. His fontanelle is bulging, respirations are irregular, and bruises mark his upper arms and chest. His parents describe a fall from a sofa onto carpet two days earlier; CT now shows falcine and convexity subdural hemorrhage without a skull fracture. The immediate problem is possible secondary brain injury. In parallel, the mismatch between the history and findings demands a careful evaluation for abusive head trauma (AHT). [\[1\]](#cite-1 "Reference [1]") First, protect the brain ------------------------ ### Stabilization before investigation Assess airway protection, ventilation, perfusion, glucose, pupils, and serial neurologic status. Irregular breathing and lethargy warrant urgent pediatric critical care and neurosurgical involvement; avoid hypoxemia and hypotension, treat seizures if present, and reassess for evolving mass effect. The safeguarding workup must not delay stabilization. [\[1\]](#cite-1 "Reference [1]") Obtain a precise, nonleading account of the fall: who witnessed it, the infant’s position, the surface struck, immediate symptoms, and the subsequent timeline. Examine the entire skin, mouth, ears, and head; record bruise location and size. Bruising in a nonmobile infant raises concern, but neither the history nor a single injury establishes the mechanism. Short falls can occasionally cause serious injury, although the described pattern merits investigation. [\[1\]](#cite-1 "Reference [1]") Read the imaging without overdating it -------------------------------------- ### CT answers the emergency question; MRI adds context Noncontrast head CT rapidly identifies hemorrhage and injuries requiring intervention. Once clinically stable, obtain brain MRI with diffusion-weighted and susceptibility-sensitive sequences to assess parenchymal injury, additional blood products, and hypoxic-ischemic injury. Discuss spinal MRI with radiology and the treating team when cervical or other spinal injury is difficult to exclude. MRI is complementary to CT, not a reason to postpone urgent care. [\[1\]](#cite-1 "Reference [1]") Mixed-density subdural blood **does not prove repeated episodes of injury**. Unclotted blood, serum, or CSF admixture can produce mixed attenuation during an acute event; imaging alone cannot assign a precise injury date. Similarly, the absence of a skull fracture neither excludes inflicted injury nor identifies shaking as the sole mechanism. Head acceleration–deceleration and impact can contribute to subdural bleeding, while apnea, impaired perfusion, and seizures may amplify subsequent brain injury. [\[2\]](#cite-2 "Reference [2]") > **Clinical pearl:** Describe what the scan shows before proposing when or how it happened. Mixed attenuation is a finding—not a clock. [\[2\]](#cite-2 "Reference [2]") Test competing explanations, not just the leading one ----------------------------------------------------- ### Four medical differentials worth defending at the board The platelet count and age-appropriate PT/aPTT are reassuring but do not close the bleeding-disorder differential. Select further testing from the history, examination, and hematology assessment rather than ordering indiscriminately. [\[3\]](#cite-3 "Reference [3]") - **Hemophilia A or B:** Severe disease commonly prolongs aPTT; mild disease may not. Factor assays are appropriate when the history or evaluation supports them. - **Late vitamin K deficiency bleeding:** Ask whether intramuscular vitamin K was given at birth and about feeding or cholestatic disease. PT is typically prolonged, sometimes before aPTT; suspected deficiency requires prompt treatment while confirmatory evaluation proceeds. - **Glutaric aciduria type 1:** Consider it when macrocephaly, developmental concerns, characteristic imaging, or newborn-screen results support it. Urine organic acids and specialist-directed metabolic testing help evaluate the possibility. - **Leukemia or another marrow disorder:** Cytopenias, abnormal leukocytes, or blasts on CBC and smear redirect the assessment; a normal platelet count alone is not a complete evaluation. [\[3\]](#cite-3 "Reference [3]") If concern for a bleeding disorder persists despite normal screening tests, consult hematology. Factor XIII deficiency is a rare but important example that routine PT and aPTT do not reliably detect. A medical predisposition to bleeding also does not, by itself, explain away injuries elsewhere. [\[3\]](#cite-3 "Reference [3]") Look for injuries the infant cannot report ------------------------------------------ ### A coordinated occult-injury workup Arrange these investigations around clinical stability and involve child abuse pediatrics early: - **Skeletal survey:** Obtain a complete, dedicated series to assess for acute and healing fractures. Consider a follow-up survey in approximately 10–14 days to clarify findings or reveal initially occult injury. - **Ophthalmologic examination:** Request a timely dilated indirect examination by an ophthalmologist experienced with pediatric retinal findings; document number, layers, and peripheral extent of hemorrhages, ideally with images when feasible. - **Laboratory and abdominal assessment:** Review CBC, PT, and aPTT; add targeted hemostatic studies as indicated. Examine the abdomen and obtain transaminases to assess for occult injury; concerning examination findings or significant enzyme elevation may prompt abdominal imaging. [\[1\]](#cite-1 "Reference [1]") Numerous, multilayered retinal hemorrhages extending into the periphery—especially with retinoschisis or perimacular folds—strongly support severe head trauma and, in this context, AHT. They are not independently diagnostic of abuse; severe accidental trauma and uncommon medical conditions remain considerations. Conversely, a normal retinal examination does not rule out AHT. [\[1\]](#cite-1 "Reference [1]") Safeguarding and prognosis -------------------------- If a caregiver later says he “shook the baby a little,” document those words verbatim, without labeling the statement a definitive explanation of every injury. Promptly report reasonable suspicion to the designated child-protection authority under local law; proof is not required before reporting. Coordinate with safeguarding staff and the responsible authorities on a safe disposition, and identify siblings who may need assessment. Clinical care and objective documentation continue while the investigation proceeds. [\[4\]](#cite-4 "Reference [4]") Poor neurologic status, apnea, extensive ocular injury, and MRI evidence of diffuse hypoxic-ischemic injury heighten concern for adverse outcome, but none predicts an individual child’s course with certainty. Survivors need longitudinal assessment for developmental, motor, seizure, and visual difficulties. Explain both the immediate findings and the uncertainty to caregivers without compromising the safeguarding process. [\[1\]](#cite-1 "Reference [1]") Key Points for Board Exams -------------------------- - Stabilize breathing and cerebral perfusion before completing the abuse evaluation. - Use CT acutely; use MRI after stabilization to characterize parenchymal injury. - Do not equate mixed-density subdural hemorrhage with proven injuries of different ages. - Investigate bleeding disorders and other plausible mimics without delaying a safeguarding report. - Seek occult fractures and document retinal findings; interpret every result in clinical context. [\[1\]](#cite-1 "Reference [1]") The strongest case assessment is neither a reflex diagnosis nor an exhaustive test list. It is a sequence: prevent secondary injury, describe findings precisely, investigate plausible alternatives, and secure a safe plan for the infant. [\[1\]](#cite-1 "Reference [1]") Frequently Asked Questions ---------------------------- ### Does mixed-density subdural hemorrhage establish that an infant was injured more than once? No. Blood and fluid can mix during an acute event; imaging appearance alone cannot precisely date the hemorrhage. [\[2\]](#cite-2 "Reference [2]") ### Which retinal pattern is most concerning in this case? Numerous, multilayered hemorrhages extending into the retinal periphery, particularly with retinoschisis or perimacular folds. Interpret the pattern alongside the full clinical evaluation. [\[1\]](#cite-1 "Reference [1]") ### Do normal PT and aPTT exclude every bleeding disorder? No. Factor XIII deficiency and some mild factor deficiencies can escape routine screening; further testing should follow clinical and hematology assessment. [\[3\]](#cite-3 "Reference [3]") ### Should clinicians wait for MRI or a definitive diagnosis before making a safeguarding report? No. Report reasonable suspicion promptly under applicable local law while continuing stabilization and diagnostic evaluation. [\[5\]](#cite-5 "Reference [5]") References (8) ------------------ 1. 1. [ publications.aap.org/pediatrics/article/155/3/e2024070457/201049/Abusive-Head-Trauma-in-Infants-and-Children?autologincheck=redirected ](https://publications.aap.org/pediatrics/article/155/3/e2024070457/201049/Abusive-Head-Trauma-in-Infants-and-Children?autologincheck=redirected) [↩](#cite-ref-1-1 "Back to text") 2. 2. [ American Academy of Pediatrics. Abusive Head Trauma in Infants and Children: Technical Report. Pediatrics. 2025. ](https://publications.aap.org/pediatrics/article/155/3/e2024070457/201049/Abusive-Head-Trauma-in-Infants-and-Children) [↩](#cite-ref-2-1 "Back to text") 3. 3. [ publications.aap.org/pediatrics/article-abstract/doi/10.1542/peds.2022-059276/189510 ](https://publications.aap.org/pediatrics/article-abstract/doi/10.1542/peds.2022-059276/189510) [↩](#cite-ref-3-1 "Back to text") 4. 4. [ publications.aap.org/pediatrics/article/123/5/1409/71477/Abusive-Head-Trauma-in-Infants-and-Children ](https://publications.aap.org/pediatrics/article/123/5/1409/71477/Abusive-Head-Trauma-in-Infants-and-Children) [↩](#cite-ref-4-1 "Back to text") 5. 5. [ Child Welfare Information Gateway. Mandatory Reporters of Child Abuse and Neglect. ](https://www.childwelfare.gov/pubpdfs/manda.pdf) [↩](#cite-ref-5-1 "Back to text") 6. 6. [ American Academy of Pediatrics. Evaluation for Bleeding Disorders in Suspected Child Abuse. Pediatrics. 2022. ](https://publications.aap.org/pediatrics/article/150/4/e2022059276/189510/Evaluation-for-Bleeding-Disorders-in-Suspected) 7. 7. [ American College of Radiology. ACR Appropriateness Criteria: Suspected Physical Abuse—Child. ](https://acsearch.acr.org/list/TopicNarrativePdf?topicId=101) 8. 8. [ Centers for Disease Control and Prevention. How to Protect Babies from Life-threatening Bleeding. ](https://www.cdc.gov/vitamin-k-deficiency/hcp/fact-sheet/index.html) Next step Practice Pediatrics the way boards test ----------------------------------------- - Age‑specific differentials and management - Growth, development, and immunizations - Target weak areas with smart review [ Start practicing ](https://mdster.com/user/dashboard) [ Explore Pediatrics ](https://mdster.com/speciality/pediatrics) [ View pricing ](https://mdster.com/pricing) [ Explore features ](https://mdster.com/features) No credit card required. Full access to all features\*. No commitment. Cancel anytime. \*AI SOE Examiner is limited to 10 cases monthly for Advanced & Bundle subscribers. 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